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Patient Safety Tip
of the Week
February
15, 2022
Wrong-Side
Chest Tubes
Anderson
et al. recently published an excellent comprehensive review on chest tube
management (Anderson 2022). But they omitted a key essential step
ensuring that the chest tube will be inserted on the correct side. In the early
1990s, wrong-side chest tube insertion was one of the leading wrong site
procedures in our New York Patient Occurrence Reporting and Tracking System
(NYPORTS). Failure to perform the same sort of timeout and verification process
that we use in the OR is a major reason that we still see wrong-side chest tube
insertions.
In our July 2014 What's New in the Patient
Safety World column Wrong-Sided
Thoracenteses we
noted some factors identified from wrong-side thoracenteses that would likely
also contribute to wrong-side chest tube insertions. Miller et al. (Miller 2014) reported
on 14 cases of thoracenteses performed on the wrong side outside the OR
setting. A resident performed the procedure in 10 of the cases and an attending
performed 2. An attending was present in 6 cases and a nurse was present in
just 3 cases.
The most frequent associated factor was
failure to perform a timeout (12 of the 14 cases). Laterality was missing from
the consent form in 10 cases and the site was not marked in 12 cases. Medical
image verification was not done in 7 of the 10 cases where information was
available.
They found 30 root causes in the 14 cases
(average 2.1 root causes per event). These most often included communication
issues, failure to follow policy or procedures, and equipment issues. In
several cases, the images were not available at the time of the procedure. That
is particularly problematic in todays computerized environment. If the PACS
system is down, you may not have immediate access to the images. In the old
days wed bring the actual films with us to the bedside. Today there are no
films, only the images on the computer system.
The authors also note that right-left
confusion is a common human error in many scenarios. They note one resident
knew the pleural effusion was on the left side on the x-ray but when he went
behind the patient the x-ray image in his mind reversed.
Miller et al. note a number
of strategies that are helpful in preventing such events. First is
formal standardization of Universal Protocol and timeouts for invasive
procedures anywhere, not just in the OR. Checklists, site marking, and
ultrasound localization are also useful. Learning and practicing the procedures
in a simulation environment is also encouraged. Development of a culture of
patient safety and good communication is also critical.
While education, training, and simulation are
all important, our own approach would incorporate forcing functions or
constraints, which are much more effective interventions in most solutions.
There are two good ways to ensure that a timeout gets done and force all the
appropriate elements to prevent a wrong-site, wrong-side, or wrong-patient
procedure. One is to prevent a physician from accessing the procedure tray all
alone. That is best done by requiring an order for the tray, which would
require a nurse to access the tray and accompany the physician to the patients
room (or other site where the procedure will be performed) and participate in the
timeout and the procedure. Second is to include on the outside of the sterile
procedure tray a checklist that must be completed prior to opening the sterile
tray. That checklist, of course, would include the items typically in the
Universal Protocol and timeouts (things like consent, verification of the
patient, procedure, laterality including review of relevant imaging studies,
etc.).
That
approach is borne out by another study (Barsuk
2011) that looked at lumbar punctures, thoracenteses and paracenteses
done on the medicine services at their facilities (see our June 6, 2011 Patient
Safety Tip of the Week Timeouts Outside the OR). Analyzing their processes, they found
that staff were often unaware of Universal Protocol (or perhaps unaware that it
was required not just for OR procedures, but for bedside procedures as well)
and that nurses were frequently never notified by physicians when their
patients were undergoing such procedures. In their redesigned process the
physician initiates the process by entering an order via CPOE with an
anticipated time. This order would automatically populate the nurses alert
list and provide the nurse with a timeout form and notice of a
procedure-specific supply kit to procure. Only the nurse has a key to those
procedure kits. This is a forcing function that forces the physician-nurse
communication to take place. The nurse brings the timeout checklist and the kit
to the bedside at the specified time and the nurse and physician go through the
timeout procedure, which gets documented in the EMR. Compliance with Universal
Protocol went from 16% before to 94% after implementation of this redesigned
process.
Good chest tube management includes all the
elements elegantly outlined by Anderson et al., but also begins by including
these important steps prior to breaking the seal on the procedure kit.
Some of our prior columns related to wrong-site surgery:
September 23, 2008 Checklists and Wrong Site Surgery
June 5, 2007 Patient Safety in Ambulatory Surgery
July 2007 Pennsylvania PSA: Preventing Wrong-Site
Surgery
March 11, 2008 Lessons from Ophthalmology
July 1, 2008 WHOs New Surgical Safety Checklist
January 20, 2009 The WHO Surgical Safety Checklist Delivers
the Outcomes
September 14, 2010 Wrong-Site Craniotomy: Lessons Learned
November 25, 2008 Wrong-Site Neurosurgery
January 19, 2010 Timeouts and Safe Surgery
June 8, 2010 Surgical Safety Checklist for Cataract
Surgery
December 6, 2010 More Tips to Prevent Wrong-Site Surgery
June 6, 2011 Timeouts Outside the OR
August 2011 New
Wrong-Site Surgery Resources
December 2011 Novel
Technique to Prevent Wrong Level Spine Surgery
October 30, 2012 Surgical
Scheduling Errors
January 2013 How
Frequent are Surgical Never Events?
January 1, 2013 Dont
Throw Away Those View Boxes Yet
August 27, 2013 Lessons
on Wrong-Site Surgery
September 10, 2013 Informed
Consent and Wrong-Site Surgery
July
2014 Wrong-Sided
Thoracenteses
March
15, 2016 Dental Patient Safety
May
17, 2016 Patient Safety Issues in Cataract Surgery
July
19, 2016 Infants and Wrong Site Surgery
September 13, 2016 Vanderbilts Electronic Procedural Timeout
May
2017 Another Success for the Safe Surgery
Checklist
May
2, 2017 Anatomy of a Wrong Procedure
June
2017 Another Way to Verify Checklist Compliance
March
26, 2019 Patient Misidentification
May
14, 2019 Wrong-Site
Surgery and Difficult-to-Mark Sites
May 2020 Poor Timeout Compliance: Ring a Bell?
September 14, 2021 Wrong
Eye Injections
October 5, 2021 Wrong
Side Again
November 9, 2021 Ensuring
Safe Site Surgery
References:
Anderson
D, Chen SA, Godoy LA, et al. Comprehensive Review of Chest Tube Management: A
Review. JAMA Surg 2022; Published online January 26, 2022
https://jamanetwork.com/journals/jamasurgery/fullarticle/2788397
Miller
KE, Mims M, Paull DE, et al. Wrong-Side Thoracentesis: Lessons Learned From Root Cause Analysis. JAMA Surg.
2014; 149(8): 774-779
https://jamanetwork.com/journals/jamasurgery/fullarticle/1879844
Barsuk
JH, Brake H, Caprio T, Barnard C, Anderson DY, Williams MV. Process Changes to
Increase Compliance With the Universal Protocol for
Bedside Procedures. Arch Intern Med. 2011; 171(10): 941-954
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/487053
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